Penile Cancer Staging Modifications to the 6th Edition TNM Staging System

The TNM staging system is a widely accepted staging tool. However, deficiencies in the 6th edition of the American Joint Committee on Cancer (AJCC) were highlighted in a report of 513 cases treated over a 50-year period at a single center.1 They described no difference in survival between stages T2 and T3 and nodal stages N1 and N2. Importantly based upon their own data they recommended changes in the staging system (i.e., the existing sixth edition TNM) with more meaningful prognostic stratification. This modified TNM system was relevant in that the variables examined were a part of routine clinical staging in distinction to the 6th edition TMN which is in essence a pathologic system.

On January 1, 2010, the 7 th edition of the unified TNM staging for penile cancer became standard.4 This represents a consensus between representatives of the American Joint Committee on Cancer (AJCC) and Union Internationale Contre le Cancer (UICC). This is the first change in the official TNM penile cancer staging since 1987 and includes a number of significant changes:

• T1 is subdivided into T1a and T1b, based on lymphovascular invasion (LVI) and grade. This has the practical division of T1 into high and low risk for selecting patients for ILND, when inguinal nodes are clinically impalpable.

• Invasion of the prostate has moved from T3 to T4, with T3 denoting urethral invasion only.

• There is provision for clinical and pathologic lymph node assessment. The distinction between superficial and deep inguinal lymph nodes has been eliminated.

• In the absence of nodal or metastatic disease, the new subdivision T1b becomes Stage II, while T1a remains Stage I.

• Any lymph node positive disease is now at least Stage III.

Clinical and pathologic staging not only determines prognosis but forms the basis of integrating multimodal therapy in the management of advanced disease. These changes aim to clarify the management of cancer, facilitate meaningful comparison between cohorts, and support multi-institutional research. Future studies should compare the prognostic value of both the 7th edition TNM4 and that proposed by Leitje et al.1 using large data sets to determine the optimal variables that best stratify patient prognosis.

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